Project: Ghana Emergency Medicine Collaborative Document Title: Toxic Alcohols Author(s): Pamela...
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Transcript of Project: Ghana Emergency Medicine Collaborative Document Title: Toxic Alcohols Author(s): Pamela...
Project: Ghana Emergency Medicine Collaborative
Document Title: Toxic Alcohols
Author(s): Pamela Fry, MD
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Troubleshooting the Mechanical Airway Try the mnemonic “DOPES”
D = displacement O = obstruction P = pneumothorax E = equipment failure S = sedation
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Methanol Where is it found?
Wiper fluid/de-icing products Paint thinners Shoe dye Embalming fluid “Moonshine”
How are patients exposed? Primarily ingestion Possible from dermal or inhalation exposure
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Hovda KE, Wikispaces
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Methanol Metabolism leads to acidosis
Formic acid buildup Lactic acidosis
Effects of formic acid Direct optic and retinal toxicity Shifts cells to anaerobic metabolism by
inhibiting cytochrome oxidase
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Ethylene Glycol Where is it found?
Radiator anti-freeze Degreasing agents Metal cleaners
How are patients exposed? Primarily ingestion: no odor, no color,
sweet taste
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Ethylene Glycol
Glycoaldehyde
Glycolic Acid
Glyoxylic Acid Alpha-hydro
Lena Carleton, University of Michigan
Ethylene Glycol Metabolism
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Ethylene Glycol 80% hepatic metabolism 20% excreted unchanged in the urine Half-life depends on renal function Also causes acidosis
Directly from glycolic acid, glyoxylic acid, oxalic acid
Indirectly when NAD+ depletion leads to anaerobic metabolism lactic acidosis
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Isopropanol Where is it found?
Rubbing alcohol Hand sanitizers “Spirits”
How are patients exposed? Primarily ingestion
Most common in USA Less toxic than other alcohols
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Methanol Least inebriating First 24hrs (direct effects of methanol)
CNS depression Euphoria/ mild inebriation
Later symptoms (from formic acid) Visual changes
Blurred vision, decreased acuity, photophobia, “snowstorm” vision
Progresses to blindness, absent papillary response, permanent optic nerve atrophy
Parkinsonian symptoms Abdominal pain
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Isopropanol Fruity odor on breath Gastrointestinal
Abdominal pain Nausea/vomiting Upper GI bleeds
Neurologic CNS depression (may progress to coma) Nystagmus Ataxia Confusion
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Diagnostic Evaluation All laboratory based – difficult to obtain
promptly in Ghana Labs all from same sample:
Electrolytes Osmolality Ethanol level Toxic alcohol levels
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Evaluating Labs Calculate serum osmolality
Measure serum osmolality Calculate osmolar gap Calculate anion gap Check urine for calcium oxalate crystals
Definitive: toxic alcohol concentration
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Evaluating Labs Ethylene glycol:
Hypocalcemia Renal failure Low bicarbonate
Methanol: Low bicarbonate
Isopropanol No anion gap Falsely elevated creatinine
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Treatment AlgorithmOne or more of the following criteria:
- anion gap >12- osmolar gap >10
- ethylene glycol >20 mg/dL- methanol > 20 mg/dL
- Evidence of metabolic acidosis- Evidence of renal failure
Administer fomepizole 15 mg/kg (Class II)
Ethylene glycol Methanol
Lena Carleton, University of Michigan
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Treatment Algorithm
Ethylene Glycol
1. Administer thiamine 100 mg IV AND administer pyridoxine 100 mg IV (Class III)
2. Order renal consult if:- presentation is delayed
- patient is acidemic - there are signs of renal insufficiency
3. Admit to ICU
Methanol
1. Administer folinic acid (leucovorin) 50mg IV OR administer folic acid 50 mg IV (Class III)
2. Order opthalmologic consult3. Consider renal consult for potential hemodialysis if:
- ingestions is large- presentation is delayed
- there are visual disturbances3. Admit to ICU
Lena Carleton, University of Michigan
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Toxic Alcohol Metabolism
Hovda KE, Wikispaces
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Treatment Airway, Breathing, Circulation Consider gastric aspiration
Only for LARGE ingestions Only if VERY recent (<1 hour)
Activated charcoal for coingestions Antidote
Fomepizole: $1,000 per vial; 15 mg/kg dose
Alcohol: used since 1940s with success
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Treating with Alcohol Higher affinity for ADH
68x greater than ethylene glycol 15x greater than methanol
IV or PO formulations available Goal: blood alcohol between 100 and
150mg/dL
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Treating with Alcohol IV: 10% ethanol in D5W
60-80 mg/kg loading dose 80-130 mg/kg/hr maintenance
PO: 20% ethanol Mix with orange juice 80 mg/kg loading dose 80 mg/kg/hr maintenance Chronic Alcoholics: 150mg/kg/hr
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Treating with Alcohol Side effects
Hypoglycemia (90% of patients) CNS depression Intoxication Thrombophlebitis Hypotension
Frequently require modifications in infusion rate to maintain 100mg/dL blood level
Should be admitted to ICU
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Pediatric ConsiderationsChildren who ingest more than a taste of ethylene glycol or any amount of methanol are referred by poison control centers to the ED for evaluation. In children18 months to 4.5 years of age, a mouthful is between 5 and 10 mL and could potentially result in concentrations that exceed 20 mg/dL of either toxic alcohol.No guidelines are currently available from the AACT or the AAPCC for treating children with toxic alcohol ingestion. In addition, the FDA has not officially approved fomepizole for use in children. Several case studies and case series report the administration of fomepizole to pediatric patients. Fomepizole is preferred over ethanol in children, since they are at risk for hypoglycemia (secondary to poor glycogen stores), hypothermia, and CNS depression.
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Treating Isopropanol Ingestions VERY DIFFERENT from other toxic alcohols Inhibiting ADH will make the patient
worse!
ABCs Administer PPI (hemorrhagic gastritis) Supportive care Consider co-ingestions